From the Guidelines
The next step during robotic assisted radical cystectomy with intracorporeal diversion when the anastomosis to the urethra cannot be performed due to lack of neobladder mobility is to perform additional mobilization of the neobladder. This can be achieved by further dissection of the surrounding tissues to create more length, particularly by releasing attachments to the posterior peritoneum and lateral pelvic walls 1. If this is insufficient, the surgeon should consider extending the mesentery of the bowel segment used for the neobladder creation or revising the configuration of the neobladder to allow for better reach. In some cases, additional bowel segments may need to be incorporated to gain length. If these maneuvers fail, conversion to a cutaneous diversion such as an ileal conduit may be necessary as a salvage procedure, which is a common alternative in such scenarios, as noted in guidelines for managing bladder cancer 1. The inability to achieve adequate neobladder mobility typically results from insufficient bowel length, improper positioning of the neobladder, or excessive tension on the mesentery, which must be addressed to prevent complications such as anastomotic leak or necrosis that could result from a tension-filled connection. Key considerations include ensuring the patient's suitability for a neobladder, including factors such as manual dexterity and willingness to catheterize, as well as preoperative marking for a potential stoma site 1, although the primary focus remains on optimizing neobladder mobility and achieving a tension-free anastomosis. Recent guidelines emphasize the importance of experience and volume in performing radical cystectomies, suggesting that high-volume centers may have better outcomes 1, which underscores the need for meticulous technique and decision-making in scenarios like the one described.
From the Research
Next Steps in Robotic Assisted Radical Cystectomy
When the anastomosis to the urethra cannot be performed due to lack of neobladder mobility during robotic assisted radical cystectomy and intracorporeal diversion, the next steps may involve:
- Considering alternative diversion methods, such as an ileal conduit, which can be performed intracorporeally 2, 3
- Utilizing specific maneuvers to overcome challenges during intracorporeal urethro-ileal anastomosis, as described in studies on robotic assisted radical cystectomy with intracorporeal neobladder formation 4
- Employing novel robotic platforms, such as the Hugo RAS system, which have been shown to be feasible for robot-assisted radical cystectomy with intracorporeal neobladder reconstruction 5
Key Considerations
- The choice of diversion method may depend on various factors, including patient characteristics, tumor stage, and surgeon experience 6
- Intracorporeal diversion methods, such as ileal conduit and orthotopic neobladder creation, have been shown to be feasible and effective in selected cases 2, 3
- Further studies are needed to fully evaluate the outcomes and potential benefits of robotic assisted radical cystectomy with intracorporeal diversion 4, 6
Possible Solutions
- Performing an ileal conduit diversion, which can be done intracorporeally using robotic assistance 2, 3
- Using a stepwise approach to overcome challenges during intracorporeal urethro-ileal anastomosis, as described in studies on robotic assisted radical cystectomy with intracorporeal neobladder formation 4
- Considering the use of novel robotic platforms, such as the Hugo RAS system, which may offer improved feasibility and outcomes for robot-assisted radical cystectomy with intracorporeal neobladder reconstruction 5